Medical Consultation For Patients With Hip Fracture

Medical consultation for patients with hip fracture INTRODUCTION — More than 270,000 hip fractures occur annually in the United States; this number is projected to increase substantially in the coming decades with predicted shifts in the population age [1]. Mortality from hip fracture approaches 25 percent at one year [2]. Of those who survive to six months, only 60 percent recover their prefracture walking ability, and only 50 percent recover their prefracture ability to perform activities of daily living [3]. Hospital readmission rates after initial treatment for hip fracture range from 20 percent within 30 days of discharge (for a predominantly male group of veterans) [4] to 30 percent within six months (for a group predominantly female) [5]. Early readmission correlated with medical comorbidities including fluid and electrolyte problems, renal insufficiency, and underlying cardiac and pulmonary disease [4]. Hip fracture is typically considered a surgical disease. However, medical consultants are almost universally involved in the care of these patients [6]. This topic will review the most common decisions that medical consultants are asked to make in the care of the patient with hip fracture. In particular, we will focus on: • • • • •

Timing of surgical intervention Prophylactic antibiotics Thromboembolic prophylaxis Prevention and management of delirium Assessment for underlying osteoporosis

TIMING OF SURGICAL INTERVENTION — The timing of surgery in patients with hip fracture, although ultimately set by the surgeon, is often dictated by the preoperative medical evaluation. Timing of the surgical intervention may have an important impact upon patient outcomes [7]: •

Delay in surgical repair will result in postponement of full weight bearing status, leading to delayed functional recovery.

•

Prolonged bed rest may increase the risk of medical complications, including deep venous thrombosis, pneumonia, urinary tract infection, and skin breakdown.

•

Failure to stabilize coexisting medical conditions prior to surgery may increase the risk of postoperative complications.

A number of studies have examined the effect of operative timing on postsurgical outcome [8-21]. Interpretation of these data is complicated by the fact that many studies were small and underpowered, and most did not control for the presence or severity of comorbidities, or excluded patients with complicating medical conditions. Studies that did attempt to control for comorbidities had variable outcomes [15-21]. Most studies suggest that surgical repair within 24 to 48 hours reduces mortality [15-18,21]. However, the largest study that controlled for comorbid conditions suggests that the time to surgery is primarily a marker of comorbidity [19]. In this retrospective study, 8383 patients ages 60 years and older underwent surgical repair for a hip fracture. Surgery was delayed for more than 24 hours in 2464 patients (29 percent) for medical reasons and in 1341 patients (16 percent) for other reasons. In the unadjusted analysis, a longer time to surgery was associated with greater long-term mortality. However, the mortality rate was not different after adjusting for demographic characteristics and underlying medical problems, comparing patients who had surgery more than 96 hours after admission with patients who had surgery 24 to 48 hours after admission (HR 1.07, 95% CI 0.95-1.21). The risk of decubitus (pressure) ulcer was increased in the group who had delayed surgery (OR 2.2, 95% CI 1.6-3.1). Case series and observational studies suggest that surgical repair of hip fracture within the first 24 to 48 hours of admission is associated with a decrease in one-year mortality for patients who are without

active and significant comorbid illness. A meta-analysis of 16 observational studies found that delay in operative repair beyond 48 hours was associated with significantly increased mortality at 30 days (OR 1.41, 95% CI 1.29-1.54) and at one year (OR 1.32, 1.21-1.43) [22]. Early surgery is also associated with reduced pain and decreased length of stay [20]. Given available data, it seems reasonable to suggest the following: •

Perform early surgery (within 24 to 48 hours) in patients who are medically stable and do not have significant comorbid illness. Whether to operate immediately (eg, in the middle of the night) or to wait until a more convenient time is best determined by local hospital staffing and available support, rather than by the medical consultant.

•

There does not seem to be substantial harm in waiting as long as 72 hours in patients with active comorbid medical illness, such as congestive heart failure, active infection (eg, pneumonia), unstable angina, or severe chronic obstructive pulmonary disease. Such individuals would likely benefit from more extensive preoperative evaluation and medical management of these conditions prior to repair of their fracture. (See "Estimation of cardiac risk prior to noncardiac surgery" and see "Evaluation of preoperative pulmonary risk" and see "Perioperative heart failure in noncardiac surgery").

•

Avoid delaying surgery beyond 72 hours.

•

Unless contraindicated, thromboembolic prophylaxis should be instituted in patients who are awaiting surgery (see "Thromboembolic prophylaxis" below).

•

Aggressive decubitus ulcer prevention measures should be employed in patients in whom surgery is delayed beyond 24 to 48 hours. (See "Prevention of pressure ulcers").

Preoperative morbidity — Hip fractures most commonly occur in frail older people who have significant underlying comorbidity. In this context, questions arise about the risks of proceeding to surgery with uncorrected underlying abnormalities versus the risks of delaying surgery to perform a thorough preoperative assessment and maximize preoperative status. A prospective cohort study has identified a set of major clinical criteria that would impact surgical outcome if uncorrected prior to surgery; validation of these criteria awaits further study [23]. PROPHYLACTIC ANTIBIOTICS — Prophylactic antibiotics are commonly administered to prevent wound infection following orthopedic procedures. Staphylococcus aureus was the most common organism isolated from multiple reports of wound infections in patients with hip fracture [24-30]. Studies addressing the use of antibiotic prophylaxis prior to repair of hip fracture have focused upon four main areas: • • • •

The efficacy of antibiotic therapy The timing of administration The duration of use The choice of agents

Efficacy of antibiotic prophylaxis — A systematic review of 22 controlled trials of administration of prophylactic antibiotics in 8307 patients undergoing surgical management of hip and other long bone fractures found that antibiotic prophylaxis reduced the risk of deep wound infections by 60 percent and also reduced the risk of superficial wound infections, urinary tract infections, and respiratory tract infections [31]. A meta-analysis of 15 placebo-controlled randomized trials in hip fracture surgery found that 20 patients would need to be treated with antibiotic to prevent one wound infection [32]. Timing of administration — The timing of administration of antibiotic prophylaxis has not been well studied. The only trial available to date is a cohort study of 2847 elective surgical hip procedures [33]. Patients given their first dose of antibiotics less than two hours before surgery had the lowest incidence of postoperative infection; relative risk for infection increased with antibiotic administration within three hours following surgery (RR 2.4, 95% CI 0.9-7.9); 3 to 24 hours following surgery (RR 5.8,

2.6-12.3); or 2 to 24 hours before surgery (RR 6.7, 2.9-14.7). Thus, prophylactic antibiotics should be initiated within two hours prior to surgery. Duration of therapy — The optimal course duration and number of antibiotic doses depends on the half-life of the antibiotic selected. A systematic review of randomized trials found that a single intravenous dose of an antibiotic that provides significant blood concentrations for 12 to 24 hours is as effective as multiple doses of agents with shorter half lives in preventing deep wound infections (RR 0.57, 95 % CI 0.2-1.6), superficial wound infections (RR 1.01, 0.35-2.9) [31], and urinary and respiratory tract infections [34]. However, a single dose of a short-acting parenteral antibiotic was marginally less effective than multiple doses in preventing deep and superficial wound infections [31]. Given these results, antibiotic therapy should be given to provide antibiotic concentrations for 24 hours. Therapy may be provided as two or three doses of a shorter-acting drug or a single parenteral dose of an agent that provides a minimum inhibitory concentration over 12 to 24 hours. In general, shorter-acting drugs are less costly and have a more appropriate narrow spectrum (see "Choice of agent" below). Choice of agent — The major pathogen in wound infections is Staphylococcus aureus. We suggest using a first generation cephalosporin (eg, cefazolin 1 to 2 g intravenously Q 8 hours) [35]. Vancomycin (1 g intravenously Q 12 hours) should be used in patients allergic to penicillins and cephalosporins and for those admitted to hospitals in which methicillin-resistant S. aureus and S. epidermis are a frequent cause of postoperative wound infections [36]. (See "Control measures to prevent surgical site infection"). THROMBOEMBOLIC PROPHYLAXIS — Venous thromboembolism is one of the leading causes of postoperative morbidity and mortality in patients with hip fracture. In the absence of thromboprophylaxis, the prevalence of venography-detected proximal DVT was 27 percent in a review of data from eight prospective studies of patients who had hip fracture surgery [37]. Fatal pulmonary embolism occurs in 0.4 to 7.5 percent of patients within three months of surgery for a fractured hip [37]. (See "Prevention of venous thromboembolic disease"). Factors increasing the risk of venous thrombosis include advanced age, malignancy, previous venous thromboembolism, obesity, heart failure, paralysis, or the presence of an inhibitor deficiency state (show table 1). The most common inhibitor deficiency state is activated protein C resistance, a defect usually caused by a mutation in the gene coding for coagulation factor V and known as factor V Leiden. (See "Activated protein C resistance and factor V Leiden"). The high risk associated with orthopedic surgery results from a number of factors that contribute to venous stasis, including the supine position on the operating table and the anatomic positioning of the extremity. Intimal injury can occur as a consequence of the original trauma or surgical intervention, and transient release of tissue factors may further increase the risk of thrombosis. Although thromboembolic prophylaxis is a routine aspect of the care of the patient with hip fracture, questions remain regarding the optimal agent and the timing and duration of prophylaxis. 2008 guidelines from the American College of Chest Physicians (ACCP) for the prevention of venous thromboembolism recommend prophylaxis using fondaparinux, low molecular weight heparin, an adjusted dose vitamin K antagonist, or low dose unfractionated heparin [38]. Fondaparinux — Fondaparinux is a synthetic highly sulfated pentasaccharide that binds to antithrombin (AT) with a higher affinity than heparin, and causes a conformational change in AT that significantly increases the ability of AT to inactivate factor Xa. (See "Therapeutic use of fondaparinux", section on Hip fracture surgery). In the largest randomized trial of thromboprophylactic therapy to prevent venous thromboembolism in patients with hip fracture, patients undergoing surgery for fracture of the upper third of the femur were randomly assigned to treatment with fondaparinux (2.5 mg once daily starting 4 to 8 hours postoperatively) or enoxaparin (40 mg/day starting 12 hours preoperatively) [39]. The incidence of venous thromboembolism (largely asymptomatic) by day 11 was significantly lower with fondaparinux (8.3 versus 19.1 percent). There were no significant differences in the incidence of death or major bleeding. Fondaparinux is approved by the US FDA for prevention of venous thromboembolic disease in patients with hip fracture. It is recommended as an option for first-line prophylactic therapy by guidelines from the ACCP [38]. However, it is more costly than other options.

Heparin — A systematic review of thromboprophylaxis (31 trials including 3000 patients with hip fracture) found both low dose unfractionated heparin and low molecular weight heparin to be protective against DVT (RR 0.60, 95% CI 0.50-0.71), but could not determine the superiority of either form of heparin [40]. Unfractionated heparin — Low-dose unfractionated heparin (5000 units subcutaneously twice daily) has been the agent most frequently studied for thromboembolic prophylaxis. A meta-analysis of eight studies involving 623 patients undergoing general, orthopedic, or urologic surgery found that low-dose unfractionated heparin reduced the risk of deep venous thrombosis by 64 percent compared with placebo [41]. Only two studies have looked at the use of low-dose unfractionated heparin specifically in patients with hip fracture; both found a substantial reduction in risk of venous thromboembolism, although the studies were small and had large confidence intervals [42,43]. Anticoagulation with low-dose unfractionated heparin slightly increases the risk of postoperative bleeding from a baseline rate of 2.9 percent in patients treated with placebo to 3.5 percent in patients treated with heparin [41]. Low molecular weight heparin — Low molecular weight heparin confers reduction in the risk of thromboembolic disease similar to low-dose unfractionated heparin [37,40,44]. A number of low molecular weight heparin fractions are available. Since patients undergoing surgery for hip fracture are considered to be at the highest risk for thromboembolism, high doses of low molecular weight heparin (>3400 units daily) should be given [38]. Renal impairment needs to be taken into account when deciding on doses of low molecular weight heparin, especially in elderly patients. (See "Low molecular weight heparin for venous thromboembolic disease"). Low molecular weight heparin can be given once or twice a day at a constant dose without laboratory monitoring and is associated with a lower incidence of thrombocytopenia than unfractionated heparin. As an example, one randomized, double-blind study of patients after hip surgery found that thrombocytopenia occurred in 9 of 332 patients (2.7 percent) receiving unfractionated heparin compared with none of 333 receiving low molecular weight heparin [45]. (See "Therapeutic use of heparin and low molecular weight heparin"). Studies of low molecular weight heparin report the incidence of postoperative bleeding to be similar to bleeding associated with unfractionated heparin. Low molecular weight heparin has been reported to cause bleeding or hematomas within the spinal column when used concurrently with spinal or epidural anesthesia [46]. Recommendations from the United States Food and Drug Administration (FDA) are that patients receiving epidural/spinal anesthesia who are treated with low molecular weight heparin should be monitored frequently for signs and symptoms of neurologic impairment [46]. Warfarin — Low-dose warfarin (INR of 1.5) has been compared to placebo in two controlled trials of patients with hip fracture [47,48]. Warfarin, at a target INR of 2 to 2.7, has been compared to aspirin [47]. Warfarin significantly reduces the risk of thromboembolic disease compared with placebo or with aspirin. Warfarin has not been compared directly with low-dose unfractionated heparin. Based upon studies that have compared heparin with aspirin or placebo, the magnitude of risk reduction with warfarin appears to approach that of low-dose unfractionated heparin. Low dose warfarin has been compared with low molecular weight heparin and was less effective than low molecular weight heparin (incidence of deep venous thromboembolism 21 versus 7 percent) [49]. It should be noted, however, that the target INR for warfarin in this study was only 1.5. Comparison studies using higher targeted INRs are not available. Thus, low-dose warfarin is more effective than aspirin but may be less effective than low molecular weight heparin. The need to monitor INR for appropriate treatment with warfarin is a potential drawback. However, patients who wish to avoid the discomfort of a twice daily injection may better tolerate and be more compliant with warfarin than low molecular weight heparin. Based upon the studies reviewed, we recommend a target INR of 2.5. The suggested initial oral dose of warfarin is in the range of 2 to 5 mg/day for the first two days, with the daily dose subsequently adjusted according to the INR. Initial doses at the lower end of this range are suggested for elderly patients, especially those with nutritional, hepatic, or cardiac impairment. Higher initial ("loading") doses of warfarin are not recommended. (See "Therapeutic use of warfarin").

Antiplatelet agents — A meta-analysis of 10 orthopedic trauma trials found that aspirin significantly reduced the rate of deep venous thrombosis and pulmonary embolism compared with placebo (OR 0.69 for deep venous thrombosis and 0.40 for pulmonary embolus) [50]. However, this reduction was significantly less than for other agents. •

In one double-blind, randomized controlled trial of 251 hip fracture patients, administration of low molecular weight heparin resulted in a relative risk reduction of 37 percent (95% CI 3.759.7 percent) compared with aspirin [51].

•

In another trial, 194 patients were randomly assigned to receive aspirin, warfarin or placebo following hip fracture [47]. The incidence of all thromboembolic events in the warfarin group was approximately half that observed in the placebo or aspirin groups (20 percent versus 40.9 and 46 percent for aspirin and placebo respectively).

•

In the largest trial, 13,356 patients with hip fracture were randomly assigned to receive 160 mg of aspirin or placebo for 35 days after surgery [52]. About three quarters of the patients also received another form of thromboprophylaxis (heparin or compression stockings). Patients who received aspirin had a significantly lower incidence of symptomatic DVT or pulmonary embolism (1.6 versus 2.5 percent). There was no benefit to aspirin in the subgroup who had received low molecular weight heparin. There was no difference in all cause mortality for any group, and aspirin increased the incidence of bleeding complications.

Thus, aspirin alone provides some, though suboptimal, protection against thromboembolic events after hip fracture. The ACCP recommends against the use of aspirin alone [37]. Aspirin, at a dose between 325 and 650 mg per day, should be used as sole chemoprophylaxis only in patients at highest risk for hemorrhagic complications with anticoagulants in whom the risk of bleeding outweighs the benefit of optimal DVT prophylaxis. Such patients should receive concurrent mechanical thromboprophylaxis (see "Intermittent leg compression" below). Direct thrombin inhibitors — A number of new small molecule direct thrombin inhibitors are under development. These orally active drugs offer the potential for an effective antithrombotic oral agent that does not need to be monitored (see "New anticoagulants"). Ximelagatran, the first oral direct thrombin inhibitor studied for DVT prophylaxis, was associated with hepatotoxicity [53,54]. It did not receive US FDA approval and has been withdrawn from manufacture. Dabigatran etexilate, the prodrug of the active compound dabigatran which binds directly to thrombin, is currently being investigated for prophylaxis of DVT and thromboembolic disease following hip replacement surgery [55,56]. Intermittent leg compression — Pneumatic sequential leg compression devices appear to decrease the incidence of postoperative deep vein thrombosis in urological, neurosurgical, and general surgical patients [57]. A systematic review of five trials with 487 hip surgery patients found lower pooled rates of DVT in patients treated with mechanical pumping devices (7 versus 22 percent), although methodologic flaws in the studies were noted [40]. There are no randomized trials of the combined use of mechanical and anticoagulant thromboprophylaxis in hip fracture patients, although effectiveness of this approach is suggested by at least one observational study [58]. We suggest the routine use of intermittent pneumatic compression devices in addition to anticoagulation until the patient is ambulating on a routine basis. These devices should be used with caution in the elderly delirious patient who may perceive them as a form of restraint, and in whom they may increase the risk for falls. Timing and duration of anticoagulation — The appropriate timing and duration of anticoagulation is unclear. Whether to initiate thromboprophylaxis before or immediately following surgery has been controversial. DVT may begin at the time of fracture. Most studies have examined the efficacy of prophylactic anticoagulation upon admission to the hospital. Until more definitive data are available, it seems reasonable to recommend the initiation of anticoagulation as soon as possible following fracture given the apparent low risk of bleeding complications associated with the use of the agents described above and the increased risk of thromboembolism following fracture and bed rest [6]. A short-acting

anticoagulant, such as low molecular weight heparin, or low dose unfractionated heparin, is preferable for preoperative initiation. There are few data in patients with hip fracture that address how long anticoagulant therapy should be continued. Two autopsy series suggest that the risk of thromboembolism decreases but still persists after the immediate operative period [59,60]. In one study of patients with hip fracture who did not receive antithrombotic prophylaxis, the rate of fatal pulmonary embolism declined from 1 percent at 30 days, to 0.4 percent at 60 days and to 0.2 percent at 90 days [59]. In a second autopsy series of patients who received prophylactic antithrombotic agents, the majority of fatal pulmonary emboli were observed 30 days or more following fracture repair [60]. These studies suggest that prolonged prophylaxis might be helpful in some patients. The risks of prolonged anticoagulation need to be weighed against the risk of DVT and thromboembolism. A randomized trial compared outcomes of fondaparinux given for 12 to 23 days, or 6 to 8 days postoperatively. The relative risk of venographically documented thrombosis was reduced by 95 percent in the group receiving longer treatment, but this was associated with a trend toward more major bleeding [61]. At present, it seems reasonable to continue prophylaxis until the patient is fully ambulatory and to extend prophylaxis further in patients in whom the risk of deep venous thrombosis may be increased (eg, those who experienced prolonged immobility post-repair, patients in whom surgery was delayed, or prior history of thromboembolism). Graduated compression stockings — A prospective randomized trial of graduated compression stockings, worn for a mean of 42 days, as adjunctive therapy to short-term fondaparinux in 795 patients undergoing hip surgery found no difference in the prevalence of DVT for patients treated with stockings plus fondaparinux versus fondaparinux alone [62]. While mechanical compression may be of benefit for patients in whom anticoagulation cannot be administered, routine use of graduated compression stockings is both costly and bothersome, and is not recommended for patients who can be treated with anticoagulation postoperatively. DELIRIUM — Delirium is a transient global disorder of cognition characterized by concurrent difficulty with attention, perception, thinking, memory, psychomotor behavior, and the sleep wake cycle [63,64]. It may be the most frequent complication observed in the hospitalized elderly [65]. Delirium occurs in an estimated 11 to 30 percent of elderly general medical patients [66] and in as many as 61 percent of patients with hip fracture [67]. Despite its prevalence, delirium is often unrecognized or misdiagnosed, particularly in the elderly [66]. (See "Diagnosis of delirium and confusional states"). Risk factors for the development of delirium include advanced age, history of cognitive impairment, preoperative use of psychotropic medication, greater illness severity, sensory impairment, vision impairment, dehydration and electrolyte imbalances, tobacco use, history of vascular surgery, and hip fracture on hospital admission [68-75]. Common precipitating factors include physical restraints, urinary catheters, iatrogenic medical complications, more than three new medications (show table 2), and malnutrition [71]. In one study, over half of the cases of delirium in patients with hip fracture occurred after surgery [76]. Most cases had multifactorial etiologies; the most common causes included sensory/environmental, infection, drug use, and fluid/electrolyte disturbance. A systematic review found that regional anesthesia, compared to general anesthesia, was associated with a reduced risk for acute postoperative confusion [77]. Pain increases the risk of delirium in patients and adequate analgesia can decrease this risk [78-80]. Although opioids produce sedation and may also be associated with delirium [81], the beneficial effect of controlling perioperative pain appears to outweigh the risk for most opioids; on balance perioperative opioid use does not increase, and may decrease, the risk of delirium [79,80]. Meperidine, however, appears to have a particularly strong association with delirium, and should be avoided [80]. (See "Prevention and treatment of delirium and confusional states", section on Opioids). Another etiology of delirium to be considered is benzodiazepine or alcohol withdrawal in patients with substance dependence prehospitalization. History obtained from the patient or family and physical exam findings can suggest the diagnosis of withdrawal. (See "Identification and management of alcohol use disorders in the perioperative period" and see "Sedatives and hypnotics: Clinical use and abuse" and see "Prevention and treatment of delirium and confusional states"). Delirium in hospitalized patients increases the length of stay, risk of complications, mortality, and institutionalization [82-86]. Delirium in patients with hip fracture can interfere with rehabilitation activities and delay the return to weight bearing.

Prevention and management — The majority of patients who develop delirium have at least some persistent symptoms six months later. Thus, prevention and appropriate treatment of delirium is an important aspect of patient management. Treatment strategies are not as effective as prevention [87]. There are four basic principles of delirium prevention and therapy (show algorithm 1) (see "Prevention and treatment of delirium and confusional states"): • • • •

Avoid factors known to cause or aggravate delirium Identify and treat the underlying acute illness Provide supportive and restorative care to prevent further physical and cognitive decline Control dangerous and disruptive behaviors so the first three steps can be accomplished.

Prevention — Early geriatrics consultation may be helpful. A randomized trial of 126 patients over the age of 65 admitted for surgical repair of hip fracture found that proactive geriatrics consultation reduced the risk of delirium compared with usual care (32 versus 50 percent) [88]. One case of delirium was prevented for every 5.6 patients in the geriatrics consultation group. Ten components of care were included in the consultation: • • • • • • • • • •

Adequate oxygen supply for CNS function Fluid and electrolyte balance Treatment of pain Eliminating unnecessary medication Management of bowel and bladder function Adequate nutrition Early mobilization Identify and treat postoperative complications Environmental stimulation Treat agitation

Other preventive interventions have been evaluated in nonrandomized studies. •

One study compared a multicomponent intervention (geriatric assessment, oxygen therapy for hypoxia, early surgery, and aggressive treatment of perioperative blood pressure falls) in 103 subjects with hip fracture, compared to 111 historical controls [89]. The incidence of delirium during the first seven postoperative days was 61 and 48 percent in the historical controls and the treatment group, respectively. Subjects in the intervention group were less likely to be confused for more than seven days and had a shorter length of stay.

•

A nursing intervention that included "preventive measures" (addressing strange environment, altered sensory input, loss of control and independence, immobility, and disrupted elimination patterns) and "ameliorative approaches" (related to mild confusion, sundowning, and unsafe behaviors) decreased the incidence of delirium in the first five postoperative days. Delirium occurred in 44 percent of patients who received the intervention and 52 percent in controls [90].

•

Other studies of nursing interventions in the medically ill elderly, however, revealed no significant differences in the development of delirium, although one study [91] found that the intervention cohort had shorter duration and decreased severity of delirium [91-93].

Pharmacologic prophylaxis for delirium has not been well studied. One randomized control trial evaluated the use of low dose haloperidol (1.5 mg/day) in 430 hip surgery patients aged 70 years or older who were at risk for delirium based on visual impairment, cognitive impairment, dehydration, and illness severity [94]. Haloperidol was started preoperatively and continued for up to three days postoperatively. The incidence of postoperative delirium was not reduced in the treatment group, although haloperidol-treated patients had a decrease in duration of delirium and hospitalization.

Treatment — Once delirium has developed, there is little evidence that intervention can improve outcome. A randomized trial to assess the impact of geriatric assessment on the management of delirium in the medically ill elderly found no significant effect on mental status, behavioral assessment, use of restraints, length of stay, discharge site, or mortality rate [95]. Low-dose neuroleptics (eg, haloperidol) and occasionally benzodiazepines may be necessary in some patients for prompt symptom control to prevent harm or allow evaluation and treatment. However, benzodiazepines may increase confusion, and most neuroleptics increase risk for extrapyramidal side effects, especially in higher doses and in elderly patients; the atypical antipsychotics risperidone and olanzapine may be preferable. All antipsychotics carry a black box warning for an increased risk of arrhythmias and death in older patients, and should be monitored closely. (See "Prevention and treatment of delirium and confusional states", section on Psychotropic medication). Patients whose delirium interferes with care may benefit from a low-dose neuroleptic (eg, haloperidol 0.25 mg to 0.5 mg orally or intravenously every 6 hours, risperidone 0.25 mg to 0.5 mg orally twice a day, or olanzapine 2.5 mg orally once a day). These drugs should be stopped as soon as the delirium has improved. OSTEOPOROSIS — Hip fracture is a manifestation of severe osteoporosis. Approximately 20 percent of hip fracture patients will incur another fracture in the next two years [96]. Physicians and patients need to be educated on the importance of osteoporosis treatment after a hip fracture. (See "Overview of the management of osteoporosis in postmenopausal women" section on Medical intervention after fracture). Patients with a recent hip fracture should be evaluated and treated for their underlying osteoporosis [97]. 2008 guidelines from the National Osteoporosis Foundation recommend pharmacologic intervention for osteoporosis in postmenopausal women and in men who have a history of vertebral fracture, regardless of bone density findings [98]. Bone densitometry is indicated to establish a baseline to monitor treatment response, but not to determine whether to initiate treatment. Unfortunately, the majority of patients who have had fragility fractures are not evaluated for osteoporosis and do not subsequently receive antiresorptive therapy, which has been shown to reduce the risk of a second fracture [99-101]. •

In a retrospective review of 124 women with fragility fractures, over 50 percent were not receiving any treatment for osteoporosis [99].

•

In a second community-based study of 60 women over age 65 with a recent hip fracture, only 13 percent were receiving adequate treatment for osteoporosis as defined by the National Osteoporosis Foundation [100]. Forty-seven percent of women were receiving inadequate treatment and 40 percent were receiving no treatment at all.

It has been recommended that hip fracture patients maintain an adequate intake of calcium (1200 mg daily minimum) and vitamin D (400 to 800 IU daily) [97]. However, two randomized trials found no significant effect for calcium and vitamin D in fracture prevention for high risk patients [102] or patients with history of hip fracture [103]. Bisphosphonates are considered first line drugs [104]. (See "Overview of the management of osteoporosis in postmenopausal women" and see "Treatment of osteoporosis in men"). Intravenous bisphosphonates can cause serious hypocalcemia in vitamin D deficient patients; the incidence of vitamin D deficiency in hip fracture patients may exceed 50 percent [105]. A randomized trial compared annual zoledronic acid infusion (5 mg) versus placebo, initiated within 90 days of surgical hip repair, in a population of 2100 patients who had refused or been intolerant of oral bisphosphonates [106]. At median follow-up of 1.9 years, patients treated with zoledronic acid, compared to placebo, had lower rates for overall fractures (8.6 versus 13.9 percent) and decreased mortality (9.6 versus 13.3 percent), although rates of second hip fractures (2.0 versus 3.5 percent) were not significantly reduced. All patients received a loading dose of 100,000 to 125,000 units of vitamin D at least one week prior to zoledronic acid infusion. Patients also received ongoing calcium and vitamin D supplementation.

OTHER ISSUES — Other issues that arise in patients with hip fracture include nutritional management, prevention of pressure ulcers, urinary tract management, rehabilitation, and assessment of fall risk. •

Attention should be paid to prevent constipation, especially in patients who receive opioid analgesics. Stool softeners and prokinetic agents, such as senna compounds, may be helpful. Peripherally-active opioid antagonists (alvimopan or methylnaltrexone) may be helpful [107]. Patients who are eating and have not had a bowel movement in two days should be treated with gentle laxative therapy (eg, bisacodyl, magnesium citrate or magnesium hydroxide). (See "Postoperative ileus" and see "Treatment of constipation in adults").

•

Oral nutritional supplementation (eg, Ensure™ or Sustacal™, one can three times daily between meals) may be beneficial for reducing minor postoperative complications in patients with hip fracture, preserving body protein stores, and reducing the overall length of stay [108111], although a systematic review found only weak evidence based on trials with methodologic flaws [111]. Nocturnal enteral feeding should be considered for patients with moderate to severe malnutrition [112]. (See "Overview of parenteral and enteral nutrition" and see "Assessment of nutrition in the critically ill").

•

Pressure ulcers occur in 10 to 40 percent of patients hospitalized for hip fracture, and increase nosocomial infection rates and lengths of stay [113]. Use of foam or alternating pressure mattresses, compared with usual care, reduce the incidence of pressure ulcers [113]. In one report, as an example, a six-inch deep foam mattress reduced the incidence of pressure ulcers among elderly patients with hip fractures from 68 to 24 percent [114]. (See "Prevention of pressure ulcers").

•

Short-term use of indwelling urinary catheters appears to reduce the incidence of urinary retention and bladder overdistention compared with intermittent catheterization alone, without increasing the rate of urinary tract infection [115]. However, the catheter should be removed within 24 hours of surgery to prevent iatrogenic urinary infection; patients can be managed subsequently with intermittent catheterization if needed [115,116]. (See "Urinary tract infection associated with indwelling bladder catheters").

•

Early mobilization of patients after hip fracture repair is safe, although the benefits of this approach have not been conclusively demonstrated [117-119]. More frequent physical therapy (at least two sessions per day) was associated with better outcomes [3,119,120]. Intensive geriatric rehabilitation may reduce length of stay [121].

•

Exercise and balance training should be undertaken in ambulatory patients after hip fracture to reduce the risk of falls [122]. Interventions directed at specific risk factors may help prevent future falls. (See "Falls in older persons: Risk factors and patient evaluation").

•

Patients with hip fractures are at increased risk for a second fracture; risk of a second fracture is greater for older patients and patients who have a higher functional level [123]. Treatment with vitamin D is recommended to reduce fall risk and subsequent fracture in patients who have sustained a hip fracture [124,125]. (See "Treatment of vitamin D deficient states").

GUIDELINES Evidence-based guidelines for the management of hip fracture are available from New Zealand [126] and Australia [127]. Recommendations in these guidelines largely support the discussion presented in this topic. SUMMARY AND RECOMMENDATIONS •

We recommend that hip fracture surgery be performed within 48 hours of hospitalization for patients who are medically stable and without significant comorbid illness (Grade 1B).

Whenever possible, surgery should not be delayed beyond 72 hours. (See "Timing of surgical intervention" above). •

We recommend use of prophylactic antistaphylococcal antibiotics (Grade 1A). We suggest that antibiotics be initiated within two hours prior to surgery and continued to provide antibiotic concentrations for 24 hours after surgery (Grade 2B). A reasonable choice is a first generation cephalosporin (eg, cefazolin 1 to 2 g intravenously Q 8 hours for three doses) for hospitals where methicillin resistance is not prevalent; vancomycin (1 g intravenously Q 12 hours) is advised for patients allergic to penicillins or in hospitals with high rates of methicillin-resistant organisms. (See "Prophylactic antibiotics" above).

•

We recommend thromboembolic prophylaxis for patients hospitalized with hip fracture (Grade 1A). For patients in whom cost is not a limiting factor, we suggest fondaparinux (2.5 mg once daily) be given postoperatively (Grade 2A). For other patients, we recommend low-dose unfractionated heparin (5000 units twice daily), low molecular weight heparin at high doses (>3400 units daily), or warfarin with a target INR of 2.5 (Grade 2B). We suggest pneumatic leg compression as an adjunct to anticoagulation until the patient is regularly ambulatory (Grade 2C). (See "Thromboembolic prophylaxis" above).

•

We suggest initiating thromboembolic prophylaxis with a short-acting anticoagulant (eg, low molecular weight or low dose unfractionated heparin) at the time of hospitalization (Grade 2C). We suggest that thromboembolic prophylaxis be continued until the patient is fully ambulatory (Grade 2C); patients at high risk for DVT may require a longer course of anticoagulation. We recommend not prescribing postoperative graduated compression stockings for routine postoperative use (Grade 1A). (See "Timing and duration of anticoagulation" above and see "Graduated compression stockings" above).

•

Patients with hip fracture are at high risk for postoperative delirium. Underlying precipitating factors should be treated. The benefits of most opioid analgesics in achieving pain control outweigh risks for most patients. Meperidine has a particularly strong association with delirium and should not be prescribed.

We suggest treatment with a low dose of a neuroleptic (eg, haloperidol 0.25 mg to 0.5 mg orally or intravenously every 6 hours, risperidone 0.25 mg to 0.5 mg orally twice a day, or olanzapine 2.5 mg orally once a day) for patients whose agitated delirium interferes with care (Grade 2C); neuroleptics should be stopped as soon as the delirium has improved. (See "Delirium" above). •

Patients with a recent hip fracture should be evaluated with bone densitometry for underlying osteoporosis. Regardless of bone density results, hip fracture patients should be treated with pharmacologic therapy for osteoporosis. (See "Osteoporosis" above).